Against all odds

Improved hospital infrastructure, attractive incentives to doctors and paramedics are propelling the health parameters in Chhattisgarh’s Bijapur district

Among the thick forests and rough terrains in the interior districts of Chhattisgarh, thousands of tribals and locals lead a complicated life due to the internal strife of Naxalites. They are deprived of basic healthcare facilities due to shortage of doctors, staff nurses, proper hospital infrastructure. Things are changing for better and people residing in those areas now have access to better healthcare amenities. The public healthcare facilities in these Naxal stronghold areas like Bijapur, Dantewada and Sukma are showing signs of improvement.

Till a year ago, pregnancy meant complication for tribal women of the interior districts of Chhattisgarh, as many pregnant women were carried in dhola (a palanquin) to the nearby District Hospitals (DH). Many a times, the deliveries took place in the village itself, as the local population faced sudden bandhs, roads blocked by tree trunks and trenches dug to prevent people’s movement. With well-equipped DH and a decent hospital infrastructure, sufficient number of doctors, specialists like gynaecologists, paediatrician, nurses — available round the clock and follow-ups by them in Community Health Centres (CHC), Primary Health Centres (PHC), many tribal women from various districts of Chhattisgarh are opting for institutional deliveries.

Bijapur

Highly Naxal affected.!

74 per cent tribal population.!

Four local languages: Dorli, Halbi,Gondi, Telugu.!

Seven hours from nearest airport or railway station.!

Population of 2.5 lakh and scarcely populated with density: 39/sq km.!

Literacy: 40 per cent.!

No mall/ cinema theatre.!

BSNL is the service provider. !

Not a single private practitioner.!

Among them, Bijapur district, one of the top five naxal affected, home to 2.5 lakhs, got its first gynaecologist in July 2016. The DH has registered total delivery of 766 from January to September 2017. By the year end, it set to cross the 1,000 mark. Meanwhile, Sukma, home to 2.6 lakh people, mostly tribal families, got its first gynaecologist recently from Telangana.

Dr Ayyaj Tamboli

Achieving this progress in Bijapur was a step-by-step process, informs Dr Ayyaj Tamboli, District Collector, Bijapur, “The district known as the hotbed for naxal violence, with 74 per cent tribal population and not a single private practitioner, reviving the public health infrastructure, bringing in doctors, was not an easy task, but it was not impossible as well.”

Building a robust public health system

The process of making healthcare available and delivery for the tribal region made a humble beginning in May 2016. The district started with its available local funds and the vision was to provide comprehensive health improvement of tribal populations into action; and get ‘mélange’ of specialist doctors who are willing to serve in this region.

To achieve this mandate, the Government of Chhattisgarh initiated Chhattisgarh Health Systems Strengthening Project (CHSSP) for providing quality healthcare to tribal populations of the Bijapur, Sukma and Bastar region.

“The project was a joint effort by the Directorate of Health Services (DHS), Govt of Chhattisgarh (GoCG) in collaboration with UNICEF and Public Health Foundation of India (PHFI) and the main agenda was to attract and retain specialised Human Resources (HR) for health in districts of Bijapur and Sukma in Bastar region. At the time of inception of the project, almost 80 per cent of posts of specialists, including surgeons, obstetrics and gynecologists, physicians and paediatricians, were lying vacant in DH and CHCs across the Bastar region. However, after the implementation of project, Bijapur recruited 13 specialist doctors against zero before the project and Sukma recruited nine specialist doctors against zero,” a PHFI official informs.

A national-level workshop with different stakeholders from the state governments, elite medical institutions, state and national health system resource centres, NGOs providing specialists care in the region showcased that most people had very limited understanding of the districts of Chhattisgarh and believed on media hyped stories. The workshop addressed the myths and highlighted that creating an enabling environment could motivate medical officers or specialist doctors to work and sustain in such regions.

The officials found that it was not about incentives, but additional facilities like employment for spouse, school admission for kids and additional marks in PG courses are some of the perks that would attract the doctors and specialists opt to work in the Naxal heartland.

R Prasanna

“We identified that the infrastructure support and basic comfort of an individual or a family was the key component that will make the doctors opt to work in insurgency-hit areas, just like the army personnel and civil servants. So, transit hostels with good infrastructure were set up for them. Apart from it, they are given additional marks, in their PG courses, if they opt to work in such areas. Now we are planning to tie up with well-known universities so the doctors can avail their advanced studies. In certain tribal districts getting ANM, Asha workers are a challenge because of certain reservation. So, we are identifying certain tribal women who are interested with the government funding. We give them coaching and training so that they can come back and serve their own community,” says R Prasanna, Commissioner Health and Mission Director, National Health Mission, Government of Chhattisgarh (GoCG).

Social and recreational support avenues were created for doctors to have a positive social life in the calm of nature. Establishing these social avenues together with grievance-redressal mechanisms for alleviating individual and system level barriers were the paramount attraction and retention of specialist doctors.

Supporting Staff

Highly Naxal affected.!

Only 10 staff nurses in DH in May 16

Contractual appointment

Recruited 73 staff nurses for DH, CHC and PHC from DMF

Pay scale same as of NHM salary

Lab tech, pharmacists and OT technician from DMF and Jeevandeep

Explaining how the district revived the grappling public health system in the district, Tamboli, said, “We focussed on improving and creating a good infrastructure and other social support for the doctors, specialists. We converted a building inside the premises of DH into a transit hostel, which had fully furnished rooms, TV, gym, common laundry area and mess. Doctors can access the officers club, which have facilities like swimming pool so that they can feel working in a corporate set-up. Before recruiting doctors, we enrolled hospital staff and nurses, as most of the day-to-day operations are done by the nurses. The funds are made available from the District Mineral Fund (DMF) mandated under the Mines and Minerals (Development and Regulation Act), which pay a part of their royalty to the district for the development of areas and people affected by mining. Bijapur district receives a corpus of Rs 40 crore per annum. With this fund, I recruited 45 staff nurses in DH alone, apart from CHC and PHC.”

According to officials, in 2007, Bijapur DH had only one MBBS doctor and seven staff nurses. In 2013, it was increased to seven MBBS doctors and 10 staff nurses. Currently, 40 doctors work in DH, which includes 16 specialists — the surgeon is from Tamil Nadu; gynaecologist, pathologist and anaesthetist are from Uttar Pradesh; ophthalmologist from Maharashtra; Microbiologist from Andhra Pradesh and ENT doctor from Telangana. As on March 31, 2016, 42 of the 55 sanctioned posts of super specialists and medical officers were vacant at Sukma. Within six months, the vacancies were down to 18 there and 20 in Bijapur. Since April 2016, efforts by the district collector and Directorate of Health Services (DHS), Government of Chhattisgarh (GoCG), over 84 super specialists and medical officers have signed up to work in Sukma and Bijapur, where you can find CRPF camps in every five kilometeres, but not a single private hospital or clinic.

“Overall, we have done 153 cesarean operations, 514 major surgeries and minor surgeries during the last seven months. We are seeing an increase in OPD, IPD, Institutional deliveries and FP services at DH,” Tamboli says.

Bijapur district in Chhattisgarh has now turned out to be a model which has elevated the healthcare availability and delivery of the tribal region, and this is now turning out to be an example for other Left Wing Extremist states and districts, inform officials.

Designing attractive incentives

As per officials, Naxals impede three developments — construction of roads, installing mobile phone towers and buildings with permanent roofs. With such restrictions to woo the doctor fraternity to these areas, attractive and negotiable pay package were designed.

Apprising that the focus was to fill the shortage of specialist doctors and medical officers, Tamboli gave details on how a lucrative salary package was designed and says, “For a staff nurse in Raipur, a non-tribal and non-naxal and completely urban area, is paid Rs 12,500. And, if it is a non-tribal, non-naxal rural area, the package is Rs 14,000, for tribal and non-naxal, hilly areas, it is Rs 16000, Rs 18,000 for tribal and naxal infested areas and Rs 20,000, if it is a severe naxal infested area and Rs 24,000 for the most inaccessible naxal-affected areas. Similarly, in Raipur a specialist gets Rs 84,000; at the same time, working in Bijapur, the package offered was 1.87 lakhs. Thus, the differential salary is based on the difficult terrains — on how deeply naxal infected area they are willing to work. These were basic packages, but some experienced doctors and radiologists, orthopedicians, expect more, so we kept a negotiable salary bracket. Currently, we have a surgeon who is paid Rs 2.2 lakhs and was given an incentive on his performance after six months.”

The package was a shared effort by the district, state government and National Health Mission (NHM), and the central government.

“Initially, for the Human Resource (HR) 60 per cent funds were from DMF, 40 per cent NHM and state component. Now, it is in the ratio of 50:50. Apart from HR, NHM funds are used to get equipment. Some additional funds from Rashtriya Swasthya Bima Yojna (RSBY), state governments were used for upgrading mortuary, blood banks, OPD set up,” Tamboli informs.

In order to make the recruitment process fast, smooth and easy in such under-served districts, Tamboli shared a SOS WhatsApp message on medico groups and Facebook (check the image for the SOS message).

“We received over 100 responses – both from specialists and general practitioners. We asked them to send there CVs via Whatsapp and Gmail. Once they had sent, we shortlisted them and asked them to visit the facility and then decide to join, and when they reached, they were assured about the safety,” he adds.

Doctors and specialists who work for the district seem to be happily serving the community, as they inform that it is not just the incentives and perks but the people and the community respect them, which is unlikely if they work in urban areas.

Providing healthcare in naxal bosom

Arun Choudhary

Straight roads with mine-clearing vehicles, covered by thick forests on either side and incessant rains, black-topped roads snaking into the distance, 29-year-old, Arun Choudhary, a gynaecologist, from Aligarh Muslim University, was was baffled by the serenity of the place

“I got an offer to join DH Bijapur, from my Head of the Department (HOD), Seema Hakim. Initially, I was under the impression that it was Bijapur in Karnataka, but later got to know that it is Bijapur located in Bastar region. I had no apprehensions, rather the environment with no hustle bustle was pleasant. Accompanied by my wife, I wanted to check the DH facility before joining in. Soon after reaching the DH, a civil surgeon asked me to help him in the OT (operating theatre) as a mother in labour and her baby were in critical condition. The heart rate was dropping, I had no time to think. Though I was not an official employee, I immediately got into action, and after few hours, I was happy that we managed to save both the mother and the child. When I first took the baby in my hands, I decided to serve this locality,” Choudhary says.

Informing that the team of nurses are outstanding and they manage any kind of complex situation with such ease, Choudhary said, “We don’t have any specific timings, we keep getting patients with different complications. But here the patients respect us so much, I don’t think this much respect can be earned if I work in any other location.” Vector borne diseases and anemia are the main concerns here.” Choudhary’s wife, an English post graduate, now works as a teacher in government school in Bijapur.

Talking about the hospital infrastructure, Dr Kushal Sakure, obstetrician-gynaecologist, says, “The OT in Bijapur is better than the one at JN Medical College in Aligarh.”

Now, the DH has a new blood bank, operation theatres, 150 beds and a 50-bed maternal and child healthcare section.

“A month prior to the project, we used to have 32 to 44 deliveries now we conduct 104 –132 deliveries a month. Earlier, when blood was required, we used to get it from Jagdalpur, 162 kms away and only 10 to 12 blood transfusions used to happen in a year. Now we have 400 to 500 transfusions in a month. New born care units, neonates, even with birth weight of 862 grams are surviving,” Tamboli informs.

Miles to go

Trying to combat the fear factor instilled by the insurgency, getting doctors and paramedics to the rebel belt and filling the shortage with flexi-funds from National Health Mission (NHM), state government, district mineral funds (DMF), the official said that it is a 100 per cent public health contribution and the private sector or the Public Private Partnership (PPP) has not been explored.

In terms of medical care, we don’t have a single private practitioner in the district, Tamboli says. “We don’t have any MBBS operating privately as there is no such robust private sector to invest or donate to the DH. We are getting CSR funds from the National Mineral Development Corporation (NMDC), which contributes Rs 10 to 15 crore per annum for all the components like education, health, infrastrucutre like roads and electricity in Bijapur. Overall, we get about Rs 1 crore or 50 lakhs with which we procure lab equipment,” he adds.

Meanwhile, elucidating the work done in interiors of Jharkhand, another Naxal-infected state by Philips healthcare and Health MaP Diagnostics, Niraj Arora, CEO Health MaP Diagnostics, inform that they have a PPP with the Jharkhand government under which they provide tele-radiology serving an approximately 700 patients per day, and this number is growing on a daily basis.

“It is not easy to get trained medical staff in certain pockets of Jharkhand where we are operating. Also, it is tough to motivate the staff from other regions to move to these locations. However, which ever locations we have managed to find staff for our services, we have had no issues in running the medical services as on date. Availability of trained paramedics is still manageable but getting doctors for locations besides the three to four key towns is a challenge. Across two states where we are working currently, i.e. Haryana and Jharkhand, we have seen strong initiatives from the respective governments to deliver better healthcare across all key segments like nephrology, cardiology, radiology, etc . However, this will become super successful only if all the segments of healthcare delivery right up to the PHC level are engaged through PPP or an appropriate mode of delivery. In association with National Rural Health Mission (NRHM), the governments are building specific programmes for providing specialised services to the patients,” Arora says.

However, officials are worried that there will be a problem if such negotiable salary packages are replicated in plain areas, a perturbed Tamboli said, “If similar packages are given in locations like Raipur or Haryana, then it will not attract doctor’s to cater to areas which are under naxal threat. The discrepancy of the differential factor should be maintained based on the difficulty of the terrain. We have miles to go to bring in a robust public healthcare system in these under-served districts.”

Informing that Bijapur model being successful, the same is being replicated in Sukma and Dhantewada and similar model is looked upon by the Odisha government for Malkangiri district, Tamboli adds that this model can be further extended to similar, other remote and naxal-affected districts and conflict zones in India. He adds that the real challenge, would be ensuring its localised success.

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